American College of Physicians: Internal Medicine — Doctors for Adults ®


The MKSAP Challenge

From the October ACP Observer, copyright 2003 by the American College of Physicians.

Clinical scenario

During February, a 37-year-old male respiratory therapist is seen in your office one day after developing fever, rigors, generalized muscle aches and mild respiratory symptoms. He is otherwise in excellent health. The patient mentions that he had not received an influenza vaccination in the fall.

Physical examination is normal except for a temperature of 39.4 C (103.0 F) and coryza. Influenza A has been documented in your community, and you have seen several patients with similar symptoms this week.

Which of the following is most appropriate for managing this patient?

A. Obtain a chest radiograph and blood cultures.
B. Obtain a nasopharyngeal culture for influenza and treat only if the result is positive.
C. Prescribe either amantadine, rimantadine, zanamivir or oseltamivir.
D. Prescribe a fluoroquinolone antibiotic.
E. Administer an intramuscular or intravenous dose of ceftriaxone and prescribe azithromycin.

Answer: C

Educational Objective: Understand how to diagnose and treat influenza during a community outbreak.

This patient likely has influenza based on the clinical presentation and the epidemiologic information. Empiric treatment is appropriate for someone who presents within 48 hours with a compatible illness if influenza has been documented in the community. However, empiric therapy for influenza alone would be inappropriate if the patient possibly had pneumonia, which would require additional evaluation for a bacterial source.

Therapy would also be inappropriate if the epidemiologic data were not consistent with influenza (for example, if a patient presents during the summer and has not recently traveled outside the Northern Hemisphere). Any of the four drugs listed can be used to treat influenza A, although only the neuraminidase inhibitors (zanamivir and oseltamivir) would be appropriate if influenza B had been documented in the community.

Chest radiograph and blood cultures are unnecessary for a patient without concomitant medical problems and no signs of lower respiratory tract infection. A nasopharyngeal culture might be useful for epidemiologic purposes.

However, it would not be helpful for deciding whether to treat this patient, as results of virus cultures require several days but therapy should be started within the first two days of symptom development and is continued for only five days. Antibacterial agents are not indicated because this patient has no suggestion of pneumonia or bacterial sinusitis.

Reference. Bridges CB, Fukuda K, Uyeki TM, Cox NJ, Singleton JA; Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2002;51(RR-3):1-31.

The above feature contains questions and answers from MKSAP 13, the latest version of the College's popular self-assessment program. For more information on MKSAP 13, go online. To order MKSAP 13, contact ACP Customer Service at 800-523-1546, ext. 2600, or 215-351-2600.


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